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- GENERAL: Alert, calm, conversant in NAD

- HEAD: Normocephalic, atraumatic

- EYES: Clear without discharge. No photophobia

- ENT: No stridor, drooling, trismus or dysphonia. Moist

- NECK: Trachea midline. Supple

- LUNGS: Unlabored respirations.  No splinting. No rales.  No wheezing.

- HEART: Normal rate. Regular. Normal heart sounds.

- CHEST: No tenderness

- ABDOMEN: Soft, non-tender. No guarding. No rebound


- SPINE: No deformity noted.

- EXTREMITIES: No edema. No tenderness. Homan’s negative. Symmetric pulses

- NEUROLOGIC: Normal speech. No focal weakness. Alert and oriented.

- PSYCHIATRIC: Normal mood. No SI

- SKIN: No erythema.

from emresource.org

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